Table Of ContentViolence: The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-patient and
Emergency Departments Guideline
APPENDIX 1:
GUIDELINE DEVELOPMENT GROUP MEMBERSHIP AND
ACKNOWLEDGEMENTS
Kevin Gournay (Group Leader), Professor of Psychiatric Nursing, Health Services
Research Department, Institute of Psychiatry
William Bingley, Professor of Mental Health, Law and Ethics, Faculty of Health,
University of Central Lancashire
Tony Bleetman, Consultant in Accident and Emergency Medicine, Birmingham
Heartlands Hospital
Frank Corr, Executive Director, Kneesworth House Hospital
Jane Cronin-Davis, Senior Lecturer in Occupational Therapy, Faculty of Health,
Leeds Metropolitan University
Donna-Maria Fraher, Southern Derbyshire User Voice
Edwin Gwenzi, Research Fellow, Health Services Research Department, Institute of
Psychiatry
Phil Hardy, Chairman for the Institute of Conflict Management (previously Andrew
McKenzie-James)
Susan Johnston, Senior Lecturer/Consultant, Rampton Hospital, Nottinghamshire
Healthcare NHS Trust
Sophie Jones, National Voices Forum
Stephen Pereira, Consultant Psychiatrist, Pathways, National Association of
Psychiatric Intensive Care Units (NAPICU), Goodmayes Hospital
Peter Pratt, Chief Pharmacist, Community Health Sheffield NHS Trust and
Doncaster and South Humberside NHS Trust
Aki Tsuchiya, Health Economist, School of Health and Related Research (ScHARR),
University of Sheffield
Rick Tucker, Professional Adviser for Mental Health and Learning Disabilities
Nursing
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National Collaborating Centre for Nursing and Supportive Care
Staff at the NCC-NSC who contributed to this guideline were:
Jackie Chandler, Research Assistant
Gill Harvey, Director
Jo Hunter (previously Robin Snowball), Information Specialist
Elizabeth McInnes, Senior R&D Fellow
Louise Nelstrop, R&D Fellow
Edward Weir, Centre Manager
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Violence: The Short Term Management of Disturbed/Violent Behaviour in Psychiatric in-patients and
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APPENDIX 2:
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE
SCOPE
Guideline title
Disturbed (violent) behaviour: the short-term management of disturbed (violent)
behaviour in in-patient psychiatric settings.
Short title
Disturbed (violent) behaviour.
Background
a) The National Institute for Clinical Excellence (‘NICE’ or ‘the Institute’) has
commissioned the National Collaborating Centre for Nursing and Supportive
Care (NCC-NSC) to develop a clinical guideline on the short-term
management of disturbed (violent) behaviour in in-patient psychiatric settings
for use in the NHS in England and Wales. This follows referral of the topic by
the Department of Health and National Assembly for Wales (see Appendix).
The guideline will provide recommendations for good practice that are based
on the best available evidence of clinical and cost effectiveness.
b) The present guideline will update and extend the previously published
guidance Management of imminent violence: clinical practice guidelines to
support mental health services produced by the Royal College of Psychiatrists
(1998).
c) For the purposes of the present guideline, short-term management is defined as
the response to disturbed (violent) behaviour occurring immediately before or
after the event, with consideration of interventions that extend to no more than
three days after the disturbed (violent) behaviour.
d) The Institute’s clinical guidelines will support the implementation of National
Service Frameworks (NSFs) in those aspects of care where a Framework has
been published. The statements in each NSF reflect the evidence that was used
at the time the Framework was prepared. The clinical guidelines and
technology appraisals published by the Institute after an NSF has been issued
will have the effect of updating the Framework.
Clinical need for the guideline
Disturbed or violent behaviour by an individual in an adult in-patient psychiatric
setting poses a serious risk to that individual, other service users and, particularly,
to staff. In 1998/99, an NHS Executive survey found that there were
approximately 65,000 violent incidents against staff across the NHS. The average
number of incidents in mental health/learning disability trusts was over three
times the average for all trusts. The Mental Health National Service Framework
stipulates that staff should be competent to assess the risk of violence, manage
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Violence: The Short Term Management of Disturbed/Violent Behaviour in Psychiatric in-patients and
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individuals who may become violent, and that staff should know how to assess
and manage risk and ensure safety. The effective short-term management of
disturbed or violent behaviour is a means of helping to minimise the risk of injury
to the individual patient, other service users and staff involved in these types of
incident.
The guideline
a) The guideline development process is described in detail in three booklets that
are available from the NICE website (see ‘Further information’). The guideline
development process – information for stakeholders describes how
organisations can become involved in the development of a guideline.
b) This document is the scope. It defines exactly what this guideline will (and
will not) examine, and what the guideline developers will consider. The scope
is based on the referral from the Department of Health and National Assembly
for Wales (see Appendix).
c) The areas that will be addressed by the guideline are described in the
following sections.
Population
Groups that will be covered
a) Adult service users (≥16 years) who are currently admitted to in-patient
psychiatric settings.
Groups that will not be covered
a) Adult psychiatric service users not currently admitted to in-patient settings.
b) People with learning disabilities.
c) People with a primary diagnosis of substance abuse.
d) Children or adolescents (<16 years).
e) Older persons with an organic mental disorder (for example, any form of
dementia) or a progressive neurological disease (for example, Parkinson’s
Disease).
Health care setting
a) The guideline will cover the care received from health care professionals who
have direct contact with and make decisions concerning the care of NHS
service users in adult in-patient psychiatric settings (including high, medium
and low security psychiatric hospitals and NHS hospitals).
b) The guideline will also be relevant to, but will not cover, practice regarding:
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Violence: The Short Term Management of Disturbed/Violent Behaviour in Psychiatric in-patients and
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• the medium to long-term prediction, causation and management of
violent behaviour in adult in-patient psychiatric settings
• mental health service users not currently admitted to adult in-patient
psychiatric settings
• violent incidents committed by people other than adult in-patient
psychiatric services users.
c) This is an NHS guideline. Although this guideline will address the interface
with other services, such as those provided by social services, secure settings
and the voluntary sector, it will not include services exclusive to these sectors.
Clinical management
The guideline will include advice on the short-term management of disturbed
(violent) service users in adult in-patient psychiatric settings, covering the
following areas.
a) The identification of potentially violent service users (for example, the use of
psychometric instruments, the responsibilities of staff and management, risk
assessment).
b) The use of de-escalation and other short-term psychosocial intervention
methods aimed at preventing the occurrence of violence.
c) The use of seclusion.
d) The use of physical restraint (for example, mechanical restraints, ‘control and
restraint’ procedures).
e) The use of rapid tranquillisation if short-term psychosocial intervention
methods have failed.
f) The training or education requirements for the above-mentioned interventions.
Advice on treatment options will be based on the best evidence available to the
development group. When referring to pharmacological treatments, the guideline will
normally recommend use within the licensed indications. Exceptionally, and only
where the evidence supports it, the guideline will recommend use outside the licensed
indications. The guideline assumes that prescribers will use the ‘Summary of product
characteristics’ to inform their prescribing decisions for individual service users.
Audit support within guideline
Level two audit criteria will be identified within the guideline.
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Status
Scope
This is the final version of the scope.
Guideline
The development of the guideline recommendations will begin in March 2002.
Further information
Information on the guideline development process is provided in:
• The guideline development process – information for the public and the NHS
• The guideline development process – information for stakeholders
• The guideline development process – information for national collaborating
centres and guideline development groups.
These booklets are available as PDF files from the NICE website
(www.nice.org.uk). Information of the progress of the guideline will also be
available from the website.
Referral from the Department of Health and National Assembly for Wales
The Department of Health and National Assembly for Wales asked the Institute:
“To prepare clinical guidelines for the NHS in England and Wales for the short-term
management of disturbed (violent) behaviour in in-patient psychiatric settings,
including consideration of pharmacological, physical (including seclusion and
restraint), preventative and psychosocial interventions.”
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Appendix 3: An outline of how the clinical questions deliver the remit via the scope
Remit: To prepare clinical guidelines for the NHS in England and Wales for the short-term management of disturbed/violent behaviour in in-patient psychiatric settings,
including consideration of pharmacological, physical (including seclusion and restraint), preventative and psychosocial interventions.
Interventions that must be covered by the guideline, according to the remit
A) Pharmacological B) Physical C) Preventative D)Psychosocial
(including seclusion and restraint)
How these are broken down in the scope
A1. Rapid tranquillisation B1. Restraint - physical and mechanical C1.Prediction D1.De-escalation
(includes use of pain compliance) C2.Risk factors D2.Observation
B2. Seclusion and time out C3. Environment
Four topics run across these areas and they are:
1.Training
2.Staff and service user perspectives
3.Issues of ethnicity, gender and physical disability
4.The use of these interventions and issues around admission and A&E
How there are translated into evidence reviews
1. Rapid tranquillisation 1. Restraint 1.Prediction 1. De-escalation
(also includes. PRN medication) 2. Seclusion 2. Risk factors 2. Observation
3. Environment
4. Alarms (part of environment)
1.Training
2.Staff and service user perspectives
3.Ethnicity
4.Gender
5.Physical disability
6. Admission and A&E
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The Clinical questions addressed in each evidence review
RAPID TRANQUILLISATION PHYSICAL INTERVENTIONS AND SECLUSION PREDICTION AND RISK FACTORS DE-ESCALATION
1. What is the effectiveness of brief 1. Are physical 1. What are the risk factors and
or fast acting pharmacological interventions safe and antecedents for disturbed/violent 1. Are psychosocial techniques, such as
interventions for the short-term effective for the short- behaviour in psychiatric in-patient de-escalation, effective in pre-
management of disturbed/violent term management of settings? Do they have good predictive empting, dissipating or preventing
behaviour in adult psychiatric disturbed/violent validity? disturbed/violent behaviour in adult
in-patient settings? behaviour in psychiatric psychiatric in-patient settings?
2. How safe are the in-patient settings? 2. Which instruments most reliably predict
pharmacological agents that are 2. Is seclusion safe and disturbed/violent behaviour in 2. What are staff and service users’
used for rapid tranquillisation effective for the short - psychiatric settings in the short-term? views about the effectiveness and
and what are the side effects? term management of Do they have good predictive validity? appropriateness of de-escalation
3. What are staff and service users’ disturbed/violent techniques as a means of diffusing
views/perceptions about the behaviour in psychiatric 3. Are there any identifiable staff disturbed/violent and potentially
effectiveness and in-patient settings? characteristics that act as risk factors violent situations?
appropriateness of 3. What are staff and for disturbed/violent behaviour?
pharmacological interventions as service users’ perceptions
a means of intervening in a of the use of physical 4. What factors do service users and staff
disturbed/violent and interventions and report as increasing the risk of
imminently violent situation? seclusion in adult disturbed/violent behaviour?
4. How safe and effective is PRN psychiatric in-patient
medication for the short-term settings?
ENVIRONMENT AND ALARMS OBSERVATION
management of disturbed/violent
behaviour in adult psychiatric 1. What factors in the physical environment of adult psychiatric in-patient settings 1. Are psychosocial techniques, such as
in-patient settings? contribute to either the promotion or the reduction of disturbed/violent observation, effective in pre-empting
behaviour? and preventing disturbed/violent
behaviour?
2. What factors in the physical environment of psychiatric in-patient settings
reduce the risks in relation to disturbed/violent behaviour? 2. What are staff and service users’
views about the effectiveness and
3. What are staff and service users’ views about the role of the ward environment appropriateness of observation as a
in promoting or reducing disturbed/violent behaviour? means of pre-empting and preventing
disturbed/violent and potentially
4. Are personal and institutional alarms and communication devices an effective violent situations?
means of alerting staff to occurrences of disturbed/violent behaviour in adult
psychiatric in-patient settings?
5. What principles of practice are necessary to ensure the effectiveness of
personal and institutional alarms and communication devices in adult
psychiatric in-patient settings?
6. What are staff and service users’ views about the role of alarms in reducing
disturbed/violent behaviour in psychiatric in-patient settings?
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GENDER ETHNICITY SPECIAL CONCERNS
1. Does the race/ethnicity of a service user or staff
1. What impact does gender have on the 1. What special considerations are needed in the short-term
member make a difference as to how they are
short-term management of management of disturbed/violent behaviour, where the
treated when they are involved in a disturbed/violent
disturbed/violent behaviour in service user has physical disabilities?
incident in adult psychiatric in-patient settings?
psychiatric in-patient settings?
2. What are staff and service users’ perspectives of the
2. Do staff and service users perceive that the
2. What are staff and service users’ considerations needed for the short-term management of
race/ethnicity of a service user or staff member
perspectives on whether gender has an disturbed/violent behaviour, where the service user has
makes a difference as to how they are treated when
impact in the management of physical disabilities?
they are involved in a disturbed/violent incident in
disturbed/violent behaviour in
adult psychiatric in-patient settings?
psychiatric in-patient settings?
ACCIDENT AND EMERGENCY SETTINGS TRAINING STAFF AND SERVICE USER PERSPECTIVES
1. How is disturbed/violent behaviour by
1. What are the most effective 1. Do staff and service users perceive themselves as safe in psychiatric in-
psychiatric patients best managed in the
and safe training programmes patient settings?
short-term in A&E settings, immediately
for the prevention of and the 2. What impact does disturbed/violent in psychiatric in-patient settings have on
prior to admission to an adult psychiatric
short-term management of staff and/or service users?
in-patient setting?
disturbed/violent behaviour in 3. What are staff and service user attitudes towards the short-term management
adult psychiatric in-patient of disturbed/violent behaviour?
2. What are the views of staff and service
settings?
users about the short-term management
of disturbed/violent behaviour by
2. What are the views of staff and
psychiatric patients in an A&E setting?
service users about the various
training programmes in adult
psychiatric in-patient settings
and their content?
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Appendix 4:
SEARCH STRATEGIES AND DATABASES SEARCHED
Search history
The rationale for the time period covered in the searches was based on an examination
of the Royal College of Psychiatrists (RCPsych) (1998) guideline, which indicated
that the majority of studies included for consideration appeared after 1985 (68 studies
included; six studies pre-1985). Additional articles and those published before 1985
were identified through manual searches of the reference lists of retrieved studies and
through consultation with stakeholders and Guideline Development Group members.
Searches were run from 1984/5-2002/2003, depending on the review question -
see search log table below. After crosschecking all earlier studies found by our
searches against the RCPsych evidence-base, any pre-1995 studies missed by their
searches were added to the total number of articles that had been identified by the
information scientist. These were then subjected to two further sifts by two
reviewers, along with all the post-1995 studies.
All searches were updated at four to six monthly intervals, using Premedline.
NB: Search strategies undertaken for the Cochrane reviews cited in the full
guideline – that is, relating to seclusion and restraint; rapid tranquillisation and
PRN medication - are available from the NCC-NSC or Cochrane groups that
undertook the reviews.
Major databases
The major databases - MEDLINE, EMBASE, PSYCINFO, and CINAHL - were
searched for all topics. These are very large literature databases that allow entry and
refinement of complex, saveable search strategies.
Other databases
To supplement the searches, unless otherwise stated, the following databases and
web sources – which do not support searching using complex search strategies -
were searched for all or any interventions for violent behaviour etc. involving
mental disorders, including de-escalation. This included the Cochrane Library
database, which is best searched broadly, and similarly SIGLE and HMIC for
‘grey’ literature, ZETOC that only supports simple one- or two-term search
strategies, and specialist web search engines, such as BIOME.
Other databases sources are listed as follows:
AMED – Alternative Medicine Database
BNI – British Nursing Index
BIOLOGICAL ABSTRACTS
COCHRANE LIBRARY
NHS Centre for Reviews & Dissemination
Health Technology Assessment Database
ReFeR (Department of Health Research)
COIN (DH Circulars Library)
POINT (DH Publications Library)
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Description:Kevin Gournay (Group Leader), Professor of Psychiatric Nursing, Health Services Research Department, Institute of Psychiatry William Bingley, Professor of Mental
